Accreditation Services International

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Welcome to the latest Quality and Accreditation
newsletter. This newsletter will be issued on a
quarterly basis in future and the current edition
includes information on the relaunch of the
Accreditation process, 18-month revisit, 2005
re-survey and other developments in the Quality
and Accreditation Department. Your
comments/feedback are appreciated so feel free to
contact us (details overleaf) .
LATEST NEWS
Re-survey The Mater Hospital has applied for
re-survey in 2005. It is likely that this will
take place in November/December 2005.
Preparations are already underway starting with
staff information sessions and the establishment
of self assessment teams (please see overleaf).
New Website The new Quality and Accreditation
website has just been launched. This will
include links to the revised standards which were
issued by the Irish Health Services Accreditation
Board (IHSAB).
Information Sessions An information session was
held on 10th June 2004 for all staff. This gave
a brief outline of the Accreditation Process, the
new IHSAB standards and the current status of the
Mater Hospital within the process. Further
information sessions have been requested by
certain Departments and are currently being held.
If you are interested in organising one for
your area, please contact Breda Doyle on Ext.
4210.
18-month Review Visit Report The report relating
to the re-visit which took place on 13th April
2004 was received from the Irish Health Services
Accreditation Board and was very positive.
Anybody interested in reading it may contact
mfagan_at_mater.ie and a copy will be e-mailed to
them.

Revised Standards The Irish Health Services
Accreditation Board (IHSAB) have issued the
revised standards to all hospitals. These are
available to all staff on the Mater website.
Copies of the book will also be issued to each
Accreditation team member.
Office Move The Quality and Accreditation office
has recently relocated to the Inner Courtyard,
Mater Hospital.
Sr. John of the Cross
Sr. John of the Cross Award Congratulations to
the winners of the Sr. John of the Cross award
for February 2004. The Breaking Bad News
Guidelines workgroup was presented with a cheque
by Mr. Martin Cowley, Chief Executive on Monday
21st June. The hospital has decided that the
awarding of the Sr. John of the Cross will be
made through the Accreditation process. In
future all applications for this award must be
processed through one of the care and non-care
Accreditation teams.
Listed below are members of the winning
group Ms. Martina Comey, Dr. Peter Lawlor, Ms.
Eileen Lee, Ms. Bernadette Moloney, Ms. Margaret
McGrath,Ms. Niamh McHale, Ms. Mary OCarroll,
Ms. Phil ONeill, Sr. Eugene Nolan, Ms. Jenny
Tomkin, Ms. Liz Whelan, Dr. Miriam OConnor, Sr.
Mary Flynn, Mr. Karl Brogan.
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REVISED TEAMS
As you are aware, the Mater Hospital has applied
for re-survey in 2005 and it is likely that this
will take place in November/December 2005. It is
now necessary to get the Accreditation process
firmly back on track and the first stage of this
process is to establish the self-assessment
teams. Previously there were 11 teams but this
has since been increased to 15 as outlined
opposite.

• Leadership / Partnership
• Information Management
• Human Resource Management
• Environmental and Facilities Management
• Cardiac Services
• Emergency Services
• ICU / Anaesthetics
• Mental Health

• Ortho-Spinal
• Surgery 1 (MB)
• Surgery 2 (P1 A)
• Medical Emergency Department
• Medicine for Elderly
• Oncology / Haematology
• Specialised Medicine

Integrated Care Pathways
With the re-launch of the accreditation campaign
in the hospital, many changes and developments
are occurring throughout our organisation. One of
these developments is the introduction of
Integrated Care Pathways. With top down
commitment we, in the Accreditation Office, are
looking for bottom up ownership.   So, what are
Integrated Care Pathways and why does the Mater
Hospital feel so strongly about their
implementation? An Integrated Care Pathway
determines locally agreed, multidisciplinary
practice, based on guidelines and evidence, where
available, for a specific patient group. It
forms all or part of the clinical record,
documents the care given and facilitates the
evaluation of outcomes for continuous quality
improvement (National Pathways Association
1998).   In March, of this year, IHSAB (Irish
Health Services Accreditation Board) published
its second edition of their Acute Care
Accreditation Scheme Standards and Guidelines.
Within their care standards (number nine) they
explicitly state the need for Comprehensive,
co-ordinated and integrated care plans to be
developed and managed across the continuum of
care/service so that patients/clients needs are
met without gaps in the care/service delivery.
  The Mater Hospital is fully focused on
providing a patient centred service. Integrated
Care Pathways will allow us to achieve this.
However, the benefits of Integrated Care Pathways
are not just for the patient, they are for the
user too. Through the development of Integrated
Care Pathways comes ownership. Ownership
provokes a sense of belonging making us realise
that each and every member of this organisation
plays a vital role in its day-to-day
functioning.   If you are interested in
developing an Integrated Care Pathway in your
specialist area feel free to contact us at the
Accreditation Office, extension 2845 or e-mail
smcmanus_at_mater.ie.   We look forward to hearing
from you.
(Left to right)

Mary Fagan, Accreditation Assistant Tel. [phone]
e-mail mfagan_at_mater.ie Bleep 3579
Sorcha McManus, Integrated Care Pathways
Facilitator Tel. [phone] e-mail
smcmanus_at_mater.ie Bleep 3285
Breda Doyle, Locum Accreditation Manager Tel. 803
4210 e-mail bdoyle_at_mater.ie
Fax [phone]